SCPTR Training Application Form

Salt City Psychedelic Therapy & Research Psychedelic Therapy Training Program (SCPTR PTTP)

March 1, 2021 Application Form
Only complete applications will be reviewed

Please send any questions to info@scptr.org
Name:*

First NameLast Name
Company
Professional Title*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*
How did you hear about the program?*
Comments
Resume or Curriculum Vitae *

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Background & Goals Statement*

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Fewer than 1000 words. Follow instructions below Cancelof
Please include the following information in your Background/Goals statement:
1. Tell us how you hope to use this training.
2. Please share any work in any aspect with adults (not children).
  You may include your work with: individuals, families, couples, or groups; hospital-based or outpatient; in private practice; performing intake assessments and mental status exams; offering pastoral care and spiritual direction; providing palliative and hospice care; substance abuse and dependency; trauma; and/or ceremonial work.
3. Please include a description of any legal issues or License problems and the remedies to correct such problems
Professional References*

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SCPTR Psychedelic Therapy Training Application Fee$200.00

$200 charged now with Application. Application fee will be applied towards tuition.

Salt City Psychedelic Therapy & Research Psychedelic Therapy Training Program (SCPTR PTTP)